Dissecting Cellulitis

Case of Dissecting Cellulitis and a Review of the Literature

Noah S. Scheinfeld, MD
Dermatology Online Journal 9 (1): 8

St-Lukes Roosevelt Hospital Center, New York. Scheinfeld@rcn.com

Abstract

Dissecting cellulitis (also called perifolliculitis capitis abscedens et suffodiens) manifests with perifollicular pustules, nodules, abscesses and sinuses that evolve into scarring alopecia. It predominantly occurs in African American men between 20-40 years of age, but can occasionally affect other races and women too. Associated musculoskeletal findings are sometimes reported. When it occurs with acne conglobata, hidradenitis suppurativa, and pilonidal cysts, the syndrome is referred to as the follicular occlusion triad or tetrad. Its course is chronic and relapsing, and treatment is often difficult. Medical therapies include isotretinoin, antibiotics, and prednisone. Destructive therapies include X-ray therapy, surgical excision, and skin grafting. Laser epilation of hair follicles is a promising new therapy for dissecting cellulitis.

Case Report

A 20 year-old black male presented with tender nodules and alopecia in his scalp (Figures 1 and 2). He had suffered from this scalp condition for more than one year and the disease was progressing. His lesions had been incised and drained but had returned. Cultures of the lesions did not grow out organisms. He had used isotretinoin, dapsone, intralesional kenalog, and doxycycline without effect. He had a history of mild facial acne and suffered from no systemic medical diseases. He had no occupational exposure to chemicals and no family history of a similar condition. His blood chemistries were all within normal.

Discussion

Dissecting cellulitis or perifolliculitis capitis abscedens et suffodiens predominantly occurs in African American men 20-40 years of age.[1] It can rarely occur in males of other races[2] and in women or girls.[3] Familial cases have been reported.[4] This condition has been reported in the Australian,[5] French,[6] British,[7] Italian,[8] and American literature.[9] Dissecting cellulitis usually starts on the scalp vertex or occiput as a folliculitis. It expands into patches of perifollicular pustules, nodules, abscesses and sinuses. Nodules may be firm or fluctuant and pus and serous fluid can be expressed. The course is typically chronic and relapsing.[10] Different lesions can be present simultaneously and healing occurs with scarring alopecia which may be patchy or confluent.[11] Often, keloidal scars form in areas of inflammation.

Dissecting cellulitis can occur with acne conglobata, hidradenitis suppurativa, and pilonidal cysts, a syndrome referred to as the follicular occlusion triad or tetrad.[12] It has been reported to occur with pyoderma vegetans,[13] marginal keratitis,[14] and pityriasis rubra pilaris.[15] The pathophysiology is believed to involve follicular blockage in all these conditions. As material accumulates in the follicle, the follicle dilates and then ruptures. Keratin and bacteria from the ruptured follicles can initiate a neutrophilic and granulomatous response.[16] It likely represents a primary inflammatory process with secondary bacterial infection (usually with Staphylococcus aureus or Staphylococcus epidermidis).

Systemic associations have been described. Musculoskeletal problems[17] and arthropathy[18] have been reported with dissecting cellulitis and the follicular occlusion tetrad. A serious association is sternocostoclavicular hyperostosis.[19] Under lesions of dissecting cellulitis osteomyelitis of the skull has developed.[20] Squamous cell carcinoma can arise in chronic, relapsing lesions.[21] Squamous cell carcinoma is also associated with the follicular occlusion triad.[22]

Dissecting cellulitis must be distinguished from several other scalp conditions. The tendency of dissecting cellulitis to cause severe alopecia, fluctuant nodules, and sinus tracts helps to distinguish it from acne keloidalis nuchae.[23] It differs from Pseudopelade of Brocq by its lack of atrophy and "foot prints in the snow" alopecia morphology. Unlike tinea capitis, culture of dissecting cellulitis does not produce a positive fungal culture and nuchal palpation does not reveal palpable lymph nodes,[24] though reports have noted an inflammatory tinea capitis (kerion) that mimicked dissecting cellulitis in adolescents.[25] Folliculitis decalvans starts with areas of perifollicular erythema. Its follicular papules and pustules spread peripherally, leaving central scarred patches of alopecia without nodules or sinuses. Tufted folliculitis resolves with patches of scarring alopecia within which multiple hair tufts emerge from dilated follicular orifices.[26] Folliculotropic mycosis fungoides with large-cell transformation has presented as clinically similar to dissecting cellulitis of the scalp.[27] Therapies can be divided into destructive, surgical and medical. Destructive therapy of dissecting cellulitis has achieved some therapeutic success. In the 1960s, standard treatment consisted of x-ray therapy, which is effective but is no longer performed due to its chief side effect--skin cancer. C02 laser ablation has been used.[28] Recently epilation of hair follicles with the 800nm laser[29] and long-pulse non-Q-switched ruby laser[30] have been reported with good effect.

Surgery is also a possible therapy.[31] Incision and drainage of lesions is a common first step in treating these lesions. Surgical excision of lesions should be considered in severe or recalcitrant cases.[32] Wide excision of the affected areas and split thickness skin grafting has advocates.[33] Combined treatment using tissue expansion, radical excision, and isotretinoin has been used successfully.[34]

Medical therapies include antibiotics, antibiotic soaps (chlorohexidine, benzoyl peroxide), dapsone, intralesional kenalog 10-40mg/cc, zinc supplements,[35] tetracycline-type antibiotics[36] and prednisone 40-60mg/day.[37] The follicular occlusion triad in a young woman has been successfully treated with high dose oral antiandrogens and minocycline.[38] Various combination therapies have been used.[39] Isotretinoin 1mg/kg/day is reported as an effective treatment for this condition.[40,41] Medical therapy did not work in this patient.

Dissecting cellulitis remains a difficult condition to treat. Recognition of this condition allows for the early institution of therapy, which is the best chance for effective intervention. New laser therapies seem particularly promising for this recalcitrant condition.

References
1. Halder RM. Hair and scalp disorders in blacks. Cutis 1983;32(4):378-80.

2. Stites PC, Boyd AS. Dissecting cellulitis in a white male: a case report and review of the literature. Cutis 2001;67(1):37-40.

3. Ramesh V. Dissecting cellulitis of the scalp in 2 girls. Dermatologica 1990;180(1):48-50.

4. Bjellerup M, Wallengren J. Familial perifolliculitis capitis abscedens et suffodiens in two brothers successfully treated with isotretinoin. J Am Acad Dermatol 1990;23(4):752-53.

5. Dyall-Smith D. Signs, syndromes and diagnoses in dermatology, Dissecting cellulitis of the scalp. Australas J Dermatol 1993;34(2):81-4.

6. Hadida E, Sayag J, Vallette P, Dissecting cellulitis of the scalp. Bull Soc Fr Dermatol Syphiligr 1968;75(2):198.

7. Jolliffe DS, Sarkany I. Perifolliculitis capitis abscedens et suffoidiens (dissecting cellulitis of the scalp). Clin Exp Dermatol 1977; 2(3):291-3.

8. Moscatelli P, Ippoliti D, Bergamo F, Piazza P. Guess what. Perifolliculitis capitis abscedens et suffodiens. Eur J Dermatol 2001; 11(2):155-6.

9. Williams CN, Cohen M, Ronan SG, Lewandowski CA. Dissecting cellulitis of the scalp. Plast Reconstr Surg 1986;77(3):378-82.

10. Scott DA, Disorders of the hair and scalp in blacks. Dermatol Clin 1988;6(3):387-95.

11. Benvenuto ME, Rebora A. Fluctuant nodules and alopecia of the scalp, Perifolliculitis capitis abscedens et suffodiens. Arch Dermatol 1992;128: 1115-9.

12. Chicarilli ZN. Follicular occlusion triad: hidradenitis suppurativa, acne conglobata, and dissecting cellulitis of the scalp. Ann Plast Surg 1987;18(3):230-7.

13. Boyd AS, Zemtsov A. A case of pyoderma vegetans and the follicular occlusion triad. J Dermatol 1992;19(1):61-3.

14. Sivakumaran S, Meyer P, Burrows NP. Dissecting folliculitis of the scalp with marginal keratitis. Clin Exp Dermatol 2001;26(6):490-2.

15. Bergeron JR, Stone OJ. Follicular occlusion triad in a follicular blocking disease (pityriasis rubra pilaris). Dermatologica 1968;136(5): 362-7.

16. Sperling LC. Scarring alopecia and the dermatopathologist. J Cutan Pathol 2001;28(7):333-42.

17. Olafsson S, Khan MA. Musculoskeletal features of acne, hidradenitis suppurativa, and dissecting cellulitis of the scalp. Rheum Dis Clin North Am 1992;18(1):215-24.

18. Libow LF, Friar DA. Arthropathy associated with cystic acne, hidradenitis suppurativa, and perifolliculitis capitis abscedens et suffodiens: treatment with isotretinoin. Cutis 1999;64(2):87-90.

19. Ongchi DR, Fleming MG, Harris CA. Sternocostoclavicular hyperostosis: two cases with differing dermatologic syndromes. J Rheumatol 1990;17(10): 1415-8.

20. Ramasastry SS, Granick MS, Boyd JB, Futrell JW. Severe perifolliculitis capitis with osteomyelitis. Ann Plast Surg 1987;18(3):241-4.

21. Curry SS, Gaither DH, King LE Jr. Squamous cell carcinoma arising in dissecting perifolliculitis of the scalp, A case report and review of secondary squamous cell carcinomas. J Amer Acad of Dermatol 1981;6:673-8.

22. Dufresne RG Jr, Ratz JL, Bergfeld WF, Roenigk RK. Squamous cell carcinoma arising from the follicular occlusion triad. J Am Acad Dermatol 1996;35(3):475-7.

23. Luz Ramos M, Munoz-Perez MA, Pons A, Ortega M, Camacho F. Acne keloidalis nuchae and tufted hair folliculitis. Dermatology 1997;194(1): 71-3.

24. Padilha-Goncalves A. Inflammatory tinea capitis (kerion) mimicking dissecting cellulitis. Int J Dermatol 1992;31(1):66. 25. Sperling LC. Inflammatory tinea capitis (kerion) mimicking dissecting cellulitis. Occurrence in two adolescents. Int J Dermatol 1991;30(3):190-2.

26. Annessi G. Tufted folliculitis of the scalp: a distinctive clinicohistological variant of folliculitis decalvans. Br J Dermatol 1998; 138(5):799-805.

27. Gilliam AC, Lessin SR, Wilson DM, Salhany KE. Folliculotropic mycosis fungoides with large-cell transformation presenting as dissecting cellulitis of the scalp. J Cutan Pathol 1997;24(3):169-75.

28. Glass LF, Berman B, Laub D. Treatment of perifolliculitis capitis abscedens et suffodiens with the carbon dioxide laser. J Dermatol Surg Oncol 1989;15(6):673-6.

29. Boyd AS, Binhlam JQ. Use of an 800-nm Pulsed-Diode Laser in the Treatment of Recalcitrant Dissecting Cellulitis of the Scalp. Arch Dermatol 2002;138(10):1291-3.

30. Chui CT, Berger TG, Price VH, Zachary CB. Recalcitrant scarring follicular disorders treated by laser-assisted hair removal: a preliminary report. Dermatol Surg 1999;25(1):34-7.

31. Dellon AL, Orlando JC. Perifolliculitis capitis: surgical treatment for the severe case. Ann Plast Surg 1982;9(3):254-9.

32. Moschella SL, Klein MH, Miller RJ. Perifolliculitis capitis abscedens et suffodiens. Report of a successful therapeutic scalping. Arch Dermatol 1967;96(2):195-7.

33. Williams CN, Cohen M, Ronan SG, Lewandowski CA. Dissecting cellulitis of the scalp. Plast Reconstr Surg 1986;77(3):378-82.

34. Bachynsky T, Antonyshyn OM, Ross JB. Dissecting folliculitis of the scalp. A case report of combined treatment using tissue expansion, radical excision, and isotretinoin. J Dermatol Surg Oncol 1992;18(10):877-80.

35. Kobayashi H, Aiba S, Tagami H. Successful treatment of dissecting cellulitis and acne conglobata with oral zinc. Br J Dermatol 1999;141(6): 1137-8.

36. Muvdi F. Folliculitis decalvans. Med Cutan Ibero Lat Am 1980;8(4-6): 81-4.

37. Adrian RM, Arndt KA. Perifolliculitis capitis: successful control with alternate-day corticosteroids. Ann Plast Surg 1980;4(2):166-9.

38. Goldsmith PC, Dowd PM. Successful therapy of the follicular occlusion triad in a young woman with high dose oral antiandrogens and minocycline. J R Soc Med 1993;86(12):729-30.

39. Shaffer N, Billick RC, Srolovitz H. Perifolliculitis capitis abscedens et suffodiens. Resolution with combination therapy. Arch Dermatol 1992;128: 1329-31.

40. L, Williams HC, Allen BR. Dissecting cellulitis of the scalp: response to isotretinoin. Br Journal of Dermatol 1996;134:1105-8.

41. Koca R, Altinyazar HC, Ozen OI, Tekin NS. Dissecting cellulitis in a white male: response to isotretinoin. Int J Dermatol 2002;41(8):509-13.

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